“Spilled” gallstones and gallstone ileus

Introduction

Gallstones are ‘spilled”, “dropped”, “retained” or “lost” during laparoscopic cholecystectomy (LC) in up to 30% of cases. “Spilled” gallstones were reported to be associated with a large variety of infective and obstructive abdominal complications. Herein, we present a case of a gallstone ileus which occurred 15 months after LC, caused by a “spilled” gallstone which was subsequently cannibalize by the bowel.

Case report

A 66 years old female presented with a two days history of colicky abdominal pain associated with nausea and vomiting. Fifteen months prior to this admission she suffered from acute cholecystitis; ultrasound at that time revealed a thickened gallbladder wall with multiple large stones and a normal biliary tree. Liver function tests were all normal. LC was performed during which stones were spilled and “partially” retrieved. She remained asymptomatic until the present admission when the picture of bowel obstruction along with abdominal tenderness prompted a laparotomy. The cause of obstruction was found to be a 3 X 2.5 cm’ gallstone impacted in the distal ileum. The area of pylorus and first potion of the duodenum were encased in dense fibrotic tissue which was biopsied. The obstructing stone was removed through a enterotomy. Postoperative ultrasound confirmed normal sized biliary tree and upper gastrointestinal contrast study did not disclose any biliary-enteric fistula. Chemical analysis of the stone showed a 7 gram calculus consisting of 96% cholesterol, 2% calcium bilirubinate and 2% mixed bile pigments. Histology of the peripyloric fibrotic tissue reported: “fibroadipose tissue with focal chronic inflammation and enzymatic fat necrosis with foreign body type reaction”. The patient recovery was uneventful.

Discussion

Normal bile ducts and liver function tests, absence of cholecystoenteric fistula during the previous LC and at follow-up, the asymptomatic period of 15 months since LC, the history of “spillage” of gallstones during LC, the foreign body reaction around the duodenum, and the finding of a large cholesterol gallstone impacted in the terminal ileum, all point out that the obstructing gallstone did not originated from the ducts. Instead, the following sequence of events is most probable: following the LC, a large “spilled” stone adhered to the duodenum, slowly eroding it’s wall by pressure necrosis. Surrounding, dense adhesions prevented leakage of duodenal contents or abscess-formation, allowing a gradual cannibalization of the stone into the lumen of bowel.

That “spilled” gallstone can erode viscera such as the duodenum, ileum, sigmoid, and urinary ballder is well described. MEDLINE search revealed two similar cases of a delayed gallstone ileus caused by stones spilled during LC. The two patients presented with gallstone-ileus 2 and 5 months after LC; the size of the obstructing stones were 5 and 4 cm’, respectively.

Most “spilled” gallstones during LC remain probably asymptomatic but complications may present years after surgery and be life-threatening. It is imperative that the surgeon strive to avoid perforation of the gallbladder during LC. When stones are spilled , however, they should be retrieved, especially the large ones.

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I agree that spilled gallstones should be retrieved and certainly ALL large ones. In cases of gross inflammation spillage is unavoidable but loss of stones from the op. field need not occur. If the breech in the GB wall is seen and the stones are known to be small, the hole should be enlarged gently to allow a 10mm suction irrigation instrument to evacuate the stones before they escape. The opening can be enlarged progressively under good vision to control the clearance. If large stones are found we deploy a retrieval sac,place it on the anterior surface of the liver and u se a 10mm scoop forceps to place the stones in the sac as the op progresses. When the GB is free, the stones can be crushed inside the sac and suction irrigation used to clear the debris so that no enlargement of the sub-xiphoid puncture site (for the operating cannula) is needed for extraction. We have completed over 1500 consecutive LC’s without wound enlargement. The sac we use is made of strong ripstop nylon and is of large capacity; it has an integral tail with which it is retained through the operating cannula and which facilitates loading.It is available from Aesculap ( Germany and UK) and Anchor Products,Addison,illinois USA.